2020-2021 Quality Assurance Reporting Requirements

2020-2021 Quality Assurance
 Reporting Requirements

 Technical Specifications Manual
 (2020-2021 QARR/HEDIS® 2020-2021)

 New York State Department of Health
 Office of Quality and Patient Safety
 ESP, Corning Tower, Room 1938
 Albany, New York
 (518) 486-9012 / NYSQARR@health.ny.gov

 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Last revised December 8, 2020

Contents
I. Submission Requirements ............................................................................................ 1
 Organizations Required to Report ................................................................................................. 1
 Reporting Requirement Guidelines ............................................................................................... 2
 What’s New in the 2020-2021 NYS Technical Specifications?..................................................... 6
 NYS QARR Technical Specification Timeline Changes ............................................................... 6
 NYS-Specific Measure Retirement ................................................................................................ 6
 NYS-Specific New Measure Requirements ................................................................................... 6
 New HEDIS Measures Added to NYS QARR List of Required Measures .................................... 6
 Use of Supplemental Databases .................................................................................................... 6
 How to Submit QARR ..................................................................................................................... 7
 Where to Submit QARR .................................................................................................................. 7
 What to Send for QARR Submission............................................................................................. 8
 Questions Concerning the 2020-2021 QARR Submission ........................................................... 8
II. Table 1. QARR List of Required Measures ................................................................... 9
III. Audit Requirements ...................................................................................................... 21
IV. Reporting Schedule ...................................................................................................... 22
V. NYS-Specific Measures ................................................................................................. 24
 Adolescent Preventive Care ........................................................................................................ 24
 Viral Load Suppression ................................................................................................................ 25
 Initiation of Pharmacotherapy Upon New Episode of Opioid Dependence .............................. 26
 Use of Pharmacotherapy for Alcohol Abuse or Dependence .................................................... 28
 Utilization of Recovery-Oriented Services for Mental Health .................................................... 29
 Behavioral Health Measures ........................................................................................................ 31
 Employed, Seeking Employment, or Enrolled in a Formal Education Program ........................................... 32
 Stable Housing Status ................................................................................................................................... 33
 No Arrests in the Past Year ........................................................................................................................... 35
 Potentially Preventable Mental Health Related Readmission Rate 30 Days ................................................ 36
 Completion of Home and Community Based Services (CHCB) Annual Needs Assessment ....................... 38
 Prenatal Care Measures/Birth File ............................................................................................... 39
 Risk-Adjusted Low Birthweight Rate ............................................................................................................. 39
 Prenatal Care in the First Trimester .............................................................................................................. 39
 Risk-Adjusted Primary C-section .................................................................................................................. 39
 Vaginal Birth After C-section ......................................................................................................................... 39
 AHRQ Quality Indicators™ .......................................................................................................... 43
VI. Patient-Level Detail and NYS-Specific Measures Summary-Level File Submission46
VII. Medicaid HMO/PHSP, HIVSNP, and CHP Enhancement File Submission ............... 55
VIII. Crosswalk of MS-DRG and NYS APRDRG ................................................................. 60

I. Submission Requirements

 I. Submission Requirements
 2020-2021 QARR consists of measures from the National Committee for Quality Assurance’s
 (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), Center for Medicare and
 Medicaid Services (CMS) QRS Technical Specifications, and New York State-specific measures.
 The 2020-2021 QARR incorporates measures from HEDIS 2020-2021.

 Areas of performance included in the 2020-2021 QARR:
 • Effectiveness of Care
 • Access/Availability of Care
 • Experience of Care
 • Utilization and Risk Adjusted Utilization
 • Health Plan Descriptive Information
 • Measures Collected Using Electronic Clinical Data
 • NYS-Specific Measures

Organizations Required to Report
Article 44 • Medicaid and Commercial Managed Care plans (HMO/PHSP, HIVSNP) certified
licenses by the New York State Department of Health (NYSDOH) prior to 2019 must
 report all applicable QARR measures for which there are enrollees meeting the
 continuous enrollment criteria.
 • Plans certified during 2020 are required to submit enrollment by product line
 and any other measures where members meet HEDIS eligibility criteria.
 • Managed Long-Term Care Medicaid Advantage and Medicaid Advantage Plus
 plans (MA/MAPs) are not required to report QARR to NYSDOH.
 • Fully Integrated Dual Advantage (FIDA) plans are not required to report QARR to
 the Office of Quality and Patient Safety. Please email FIDA@health.ny.gov for
 information on reporting requirements to the NYSDOH.

Article 32 • Preferred Provider Organizations/Exclusive Provider Organizations (PPO/EPO)
Article 42 licensed by the New York State Department of Financial Services (DFS) prior to
Article 43 2020 must report all QARR measures if there are more than 30,000 members
Article 47 residing in New York State in PPO/EPO products as of December 31, 2020,
licenses (unless the insurer is also a QHP, then follow guidance from CMS on minimum
 threshold). Members with dental-only, vision-only, catastrophic-only, and
 student coverage-only products are excluded when determining eligible
 membership for QARR.

Article • Qualified Health Plans (QHP) licensed by DFS prior to 2020 must report all
1113(a) QARR measures. Members with dental-only and catastrophic-only products
licenses are excluded when determining eligible membership for QARR.

 1

I. Submission Requirements

 Reporting Requirement Guidelines
 • QARR List of Required Measures (Table 1) lists by product the NYS-specific and HEDIS 2020-2021
 measures required for submission.
 • This manual describes in detail only the NYS-specific measures. Plans must purchase the HEDIS
 2020-2021 Technical Specifications for descriptions of the required HEDIS measures. Qualified
 Health Plans should follow all technical guidance outlined in the Quality Rating System (QRS)
 Reporting Requirements and Guidance on the CMS website.
 • Insurers offering a QHP should follow CMS guidance on the combination of both individual and
 Small Business Health Options Program (SHOP) members in the same Exchange data collection
 unit as per CMS for QARR reporting.
 • Plans should always apply HEDIS 2020-2021 guidelines for each applicable product line when
 calculating continuous enrollment periods for NYS-specific measures.
 • All submitted data must be audited by certified auditors from NCQA Licensed Organizations.
 • Plans required to provide CAHPS data must use an NCQA-certified CAHPS vendor.
 • All clarifications to the 2020-2021 QARR will be distributed electronically to plan representatives and
 available on our web site https://www.health.ny.gov/health_care/managed_care/plans/index.htm
 under the Health Plan Guidelines section. All clarifications must be incorporated into the 2020-2021
 QARR specifications.
 • Plans must report required measures for which there is an eligible population. Plans may not
 elect to suppress reporting or designate a measure as “NR – plan chose not to report.”
 • We prefer that only data for NYS residents be included in QARR and CAHPS measures. In
 situations where commercial organizations are unable to remove out-of-state residents due to
 inclusion of contractual groups in their QARR process, the out-of-state members may be included.
 However, commercial plans should limit this to contracts originating in NYS and amend QARR
 processing in future cycles to limit out-of-state members.
 • Collection Method: If a measure is denoted as Hybrid (H) only in the QARR List of Required
 Measures (Table 1), all plans must use hybrid method for collection for all numerator non-
 compliant members. Results calculated with administrative collection only for these measures will
 be invalidated by NYSDOH if they are determined to be under-reported, even if the auditor
 determined the result to be reportable. If a measure is denoted as Administrative or Hybrid (A/H),
 NYSDOH will accept the administrative collection and reporting of these measures, unless the rate
 deviates significantly from the statewide average or last year’s rate.
 • For all NYS-specific measures, follow NCQA general guidelines for members with dual enrollment
 in Commercial/Medicaid.
 • NYS-specific measures will be reported using the NYS-Specific Patient-Level Detail file.
 NYS-specific measures will not be reported via NCQA IDSS.

 2

I. Submission Requirements

Specific Instructions for Commercial, Medicaid, and Qualified Health Plan Product Lines of
Business:
 Commercial PPO (CPPO)
 o PPO product data should be reported separately for all licensed organizations meeting the
 enrollment threshold unless there is agreement from NCQA authorizing the combining of PPO
 and HMO/POS data or the combining of PPO and EPO data.
 o NYSDOH incorporates combined PPO/HMO submissions with HMO data tables.
 o NYSDOH incorporates combined PPO/EPO submissions with PPO data tables.
 o Members who have any of the ‘medical’ benefit, as defined by HEDIS, should be included in
 the required measures. If the member has either outpatient or inpatient benefit coverage, the
 member is considered to have a ‘medical’ benefit and is included in applicable measures.
 o Commercial specifications should be followed for all required HEDIS 2020-2021 and QARR
 2020-2021 NYS-specific measures. If a required measure has only Medicaid specifications,
 commercial organizations should continue to use the commercial instructions for calculating
 the continuous enrollment portion of the measure.
 o PPO plans must use a certified CAHPS vendor and have their CAHPS sample frame
 reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.
 o NYS-Specific Measures Summary-Level File is required.

 Commercial EPO (CEPO)
 o NYSDOH incorporates combined PPO/EPO submissions with PPO data tables.
 o Members who have any of the ‘medical’ benefit, as defined by HEDIS, should be included in
 the required measures. If the member has either outpatient or inpatient benefit coverage, the
 member is considered to have a ‘medical’ benefit and is included in applicable measures.
 o Commercial specifications should be followed for all required HEDIS 2020-2021 and QARR
 2020-2021 NYS-specific measures. If a required measure has only Medicaid specifications,
 commercial organizations should continue to use the commercial instructions for calculating
 the continuous enrollment portion of the measure.
 o EPO plans must use a certified CAHPS vendor and have their CAHPS sample frame
 reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.
 o NYS-Specific Measures Summary-Level File is required.

 Commercial HMO/POS (CHMO)
 o HMO/POS product data should be reported separately for all licensed organizations meeting
 the enrollment threshold unless there is agreement from NCQA authorizing the combining of
 PPO or EPO and HMO/POS data.
 o NYSDOH incorporates combined PPO/HMO submissions with HMO data tables.
 o If plans are including their POS members with their HMO, POS is included in their commercial
 HMO rates. Follow HEDIS 2020-2021 instructions regarding commercial POS products.
 o Commercial specifications should be followed for all required HEDIS 2020-2021 and QARR
 2020-2021 NYS-specific measures. If a required measure has only Medicaid specifications,
 commercial organizations should continue to use the commercial instructions for calculating
 the continuous enrollment portion of the measure.
 o HMO/POS plans must use a certified CAHPS vendor and have their CAHPS sample frame
 reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.
 o NYS-Specific Measures Summary-Level File is required.

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I. Submission Requirements

 Commercial Off-Exchange Product
 o Off-Exchange products must include this membership in the commercial product line.
 o Plans without a Commercial product should contact NYSQARR@health.ny.gov for further
 guidance.

 Qualified Health Plan PPO (QPPO)
 o PPO product data should be reported separately for all licensed organizations meeting the
 enrollment threshold, and plans should follow CMS guidance on reporting by product.
 o Members who have any of the ‘medical’ benefit, as defined by HEDIS, should be included in
 the required measures. If the member has either outpatient or inpatient benefit coverage, the
 member is considered to have a ‘medical’ benefit and is included in applicable measures.
 o Quality Rating System (QRS) Measure Technical Specifications should be followed for all
 required measures. NYSDOH will only be collecting measures and numerators included in the
 QRS Measure set.
 o PPO plans must use an HHS-approved survey vendor and have their enrollee survey sample
 frame reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.

 Qualified Health Plan PPO (QEPO)

 o EPO product data should be reported separately for all licensed organizations meeting the
 enrollment threshold, and plans should follow CMS guidance on reporting by product.
 o Members who have any of the ‘medical’ benefit, as defined by HEDIS, should be included in
 the required measures. If the member has either outpatient or inpatient benefit coverage, the
 member is considered to have a ‘medical’ benefit and is included in applicable measures.
 o Quality Rating System (QRS) Measure Technical Specifications should be followed for all
 required measures. NYSDOH will only be collecting measures and numerators included in the
 QRS Measure set.
 o EPO plans must use an HHS-approved survey vendor and have their enrollee survey sample
 frame reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.

 Qualified Health Plan HMO (QHMO)
 o HMO product data should be reported separately for all licensed organizations meeting the
 enrollment threshold, and plans should follow CMS guidance on reporting by product.
 o Quality Rating System (QRS) Measure Technical Specifications should be followed for all
 required measures. NYSDOH will only be collecting measures and numerators included in the
 QRS Measure set.
 o HMO plans must use an HHS-approved survey vendor and have their enrollee survey sample
 frame reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.

 Qualified Health Plan POS (QPOS)
 o POS product data should be reported separately for all licensed organizations meeting the
 enrollment threshold, and plans should follow CMS guidance on reporting by product.
 o Quality Rating System (QRS) Measure Technical Specifications should be followed for all
 required measures. NYSDOH will only be collecting measures and numerators included in the
 QRS Measure set.
 o POS plans must use an HHS-approved survey vendor and have their enrollee survey sample
 frame reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.

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I. Submission Requirements

 Essential Plans (EP)
 o EP product data should be reported separately for all licensed organizations meeting the
 enrollment threshold.
 o Members who have any of the ‘medical’ benefit, as defined by HEDIS, should be included in
 the required measures. If the member has either outpatient or inpatient benefit coverage, the
 member is considered to have a ‘medical’ benefit and is included in applicable measures.
 o Commercial specifications should be followed for all required HEDIS 2020-2021 and QARR
 2020-2021 NYS-specific measures. If a required measure has only Medicaid specifications,
 commercial organizations should continue to use the commercial instructions for calculating
 the continuous enrollment portion of the measure.
 o EP plans must use a certified CAHPS vendor and have their CAHPS survey sample frame
 reviewed and approved by their auditor.
 o Patient-Level-Detail files are required.
 o NYS-Specific Measures Summary-Level File is required.

 Child Health Plus (CHP)
 o Plans with both CHP and Medicaid products will combine members for the two products for
 measure calculation and reporting. Information will be included with ‘Medicaid’ results on the
 IDSS.

 Medicaid HMO/PHSP (MA)
 o Plans with both CHP and Medicaid products will combine members for the two products for
 measure calculation and reporting. Information will be included in ‘Medicaid’ results. CHP
 members will be included in all measures where the members meet eligibility criteria.
 o Plans should follow Medicaid specifications in HEDIS 2020-2021 and QARR 2020-2021 NYS-
 specific measures for the required measures. If a required measure has only commercial
 specifications, Medicaid organizations should continue to use the Medicaid instructions for
 calculating continuous enrollment.
 o Patient-Level-Detail files are required. The fee-for-service (FFS) enhancement files are
 optional.
 o NYS-Specific Measures Summary-Level File is required.

 Medicaid HIV Special Needs Plans (HIVSNP)
 o Plans should follow Medicaid specifications in HEDIS 2020-2021 and QARR 2020-2021 NYS-
 specific measures. If a required measure has only commercial specifications, HIVSNP
 organizations should continue to use the Medicaid instructions for calculating continuous
 enrollment.
 o Patient-Level-Detail files are required. The fee-for-service (FFS) enhancement files are
 optional.
 o NYS-Specific Measures Summary-Level File is required.

 Medicaid Health and Recovery Plan (HARP)
 o Plans should follow Medicaid specifications in HEDIS 2020-2021 and QARR 2020-2021 NYS-
 specific measures. If a required measure has only commercial specifications, HARP
 organizations should continue to use the Medicaid instructions for calculating continuous
 enrollment.
 o Patient-Level-Detail files are required. The fee-for-service (FFS) enhancement files are
 optional.
 o NYS-Specific Measures Summary-Level File is required.

 Medicare and Dual Eligible
 o Plans should NOT submit information for enrollees with Medicare coverage.

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I. Submission Requirements

 What’s New in the 2020-2021 NYS Technical Specifications?
 • The Adolescent Preventive Care measure will not be collected for MY2020. We are working
 to transition these specifications away from the use of HEDIS WCC eligible population to a
 NYSDOH-defined eligible population.

 • NYSDOH will freeze the NYS QARR Technical Specifications on December 15, 2020.
 Clarifications issued after that date will not affect coding or program changes.

 NYS QARR Technical Specification Timeline Changes

 NYSDOH QARR Current Timeline Transition Year Future Timeline
 Specifications MY 2020 MY 2021 MY 2022
 Initial Specifications
 October 2020 October 2020 October 2021
 Release
 Planned Specifications
 December 2020 April 2021 April 2022
 UPDATES

 NYS-Specific Measure Retirement
 • None

 NYS-Specific New Measure Requirements

 • Utilization of Recovery-Oriented Services for Mental Health (URO)

 New HEDIS Measures Added to NYS QARR List of Required Measures
 • Cardiac Rehabilitation (CRE)- MY 2021
 • Kidney Health Evaluation for Patients With Diabetes (KED)
 • Adult Immunization Status (AIS-E)
 • Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
 • Prenatal Immunization Status (PRS-E)
 • Postpartum Depression Screening and Follow-Up (PDS-E) – MY 2021

 Use of Supplemental Databases
What are they?
Supplemental databases contain information about health care services members received that is
gathered from sources other than claims and encounters. See HEDIS 2020-2021 (General Guidelines
Volume 2, HEDIS 2020-2021) for direction on how the data may be used in the calculation of
measures, and how the information will be processed and validated with proof-of-service documents
from the legal health record.
The types of files, data sources, and collection processes dictate how the data must be captured,
managed, and verified in order to incorporate information from the database into HEDIS/QARR
reporting. NYSDOH is not adding or changing any of the HEDIS guidelines regarding the use of
supplemental databases.

How are supplemental databases used by health plans?
As directed in HEDIS guidelines, health plans are permitted to use supplemental databases to
capture information on services and events used for:
 1) numerator compliance
 2) optional exclusions
 6

I. Submission Requirements

 3) members in hospice and members who have died
 4) eligible population required exclusions not related to the timing of the denominator event or
 diagnosis.

Supplemental databases should not be used to determine denominator events, to capture for clinical
conditions that may change over time, to correct billing information, and for measures where the
specification specifically indicates supplemental data cannot be used, except for applying the hospice
exclusion and for excluding deceased members.
The information captured from data sources must comply with HEDIS 2020-2021 guidelines for
timing, file type, data elements, collection processes, and procedures for maintaining systems and
data integrity. All supplemental databases must be approved by the organization’s auditor for
inclusion in rate calculation. Plans are encouraged to contact auditors and seek approval of
processes as early as possible to ensure information is allowed for HEDIS/QARR reporting.

NYSDOH Reporting Requirements
NCQA added a data element to collect numerator events by supplemental data to all Effectiveness of
Care (EOC) measures and Utilization measures similar to EOC measures. The reporting of
supplemental numerator events in the Interactive Data Submission System (IDSS) is required.
NYSDOH does not require the reporting of supplemental numerator events for NYS-specific
measures.

 How to Submit QARR
All plans must submit QARR data on the National Committee for Quality Assurance (NCQA)
Interactive Data Submission System (IDSS). Estimated distribution date for the IDSS for MY 2020 is
March 2021 and estimated distribution date for the IDSS for MY 2021 is March 2022.

 Where to Submit QARR
• Submit the IDSS directly to NCQA.

• Electronically submit all additional files to our External Quality Review Organization
 (EQRO) via a secure file transfer facility (see Reporting Schedule for dates). Do not mail
 materials. Additional files include:

 1) Commercial CAHPS files
 2) QHP Enrollee Survey files
 3) Patient-Level-Detail files
 4) Live Birth files
 5) Medicaid Optional Enhancement files

• Coordinate FTP site arrangements with Lisa Balistreri of IPRO at ebalistreri@ipro.org.

• Any plan failing to submit the files by 11:59 p.m. ET on the date due will receive a
 Statement of Deficiency (SOD) for failure to comply with quality program requirements.
 For Medicaid plans, the compliance portion of the Quality Incentive is affected by
 Statements of Deficiency for QARR reporting.

 7

I. Submission Requirements

 What to Send for QARR Submission

The following submissions must be received electronically by 11:59 p.m. ET on June 15, 2021.

 IDSS file for all payers – IDSS files must be locked by auditor
 CAHPS de-identified member-specific file for CPPO, CEPO, CHMO, EP
 Enrollee Survey de-identified member-specific file for QEPO, QPPO, QHMO, QPOS
 Patient-Level-Detail file for all products (includes NYS-specific measures)
 Optional enhancement files for MA, HIVSNP, and HARP

The following submission must be received electronically by 11:59 p.m. ET on August 1, 2021.

 Live Birth files for all payers

 Questions Concerning the 2020-2021 QARR Submission

• Interactive Data Submission System (IDSS): https://my.ncqa.org/
• Other required files: nysqarr@health.ny.gov
• HEDIS 2020-2021 measures: Updates can be found on NCQA’s web site: www.ncqa.org. Submit
 questions to NCQA’s Policy Support System at the web site. NYSDOH is not responsible for the
 interpretation of HEDIS specifications or updating HEDIS information. Plans must refer to HEDIS
 specifications when calculating HEDIS measures as part of QARR.
• The Health Insurance Exchange Quality Rating System Measure Technical Specifications can be
 found on CMS web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
 Instruments/QualityInitiativesGenInfo/ACA-MQI/Quality-Rating-System/About-the-QRS.html
 NYSDOH is not responsible for the interpretation of The Health Insurance Exchange
 specifications or updating information. Plans must refer to CMS specifications when calculating
 the QRS measures as part of QARR.
• All other questions: Quality Measurement and Evaluation Unit at nysqarr@health.ny.gov.

 8

II. Reporting Requirements

II. Table 1. QARR List of Required Measures
 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Effectiveness of Care
 Adherence to Antipsychotic Medications HEDIS
 A SAA    NR NR    
 for Individuals with Schizophrenia 2020-2021
 NYS
A/H Adolescent Preventive Care ADL 2021 2021 NR NR NR 2021 2021 NR
 2020-2021
 Annual Monitoring for Persons on Long-
 A AMO NR NR NR   NR NR NR QRS
 Term Opioid Therapy
 HEDIS
 A Antidepressant Medication Management AMM         
 2020-2021
 HEDIS
 A Appropriate Testing for Pharyngitis CWP         
 2020-2021
 Appropriate Treatment for Upper HEDIS
 A URI         
 Respiratory Infection 2020-2021
 HEDIS
 A Asthma Medication Ratio AMR         
 2020-2021
 Avoidance of Antibiotic Treatment for HEDIS
 A AAB       NR  
 Acute Bronchitis/Bronchiolitis 2020-2021

 9
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 HEDIS
 A Breast Cancer Screening BCS         
 2020-2021
 HEDIS
 A Cardiac Rehabilitation CRE 2021 2021 2021 NR NR 2021 2021 2021 
 2020-2021
 Cardiovascular Monitoring for People
 HEDIS
 A With Cardiovascular Disease and SMC NR NR NR NR NR    
 2020-2021
 Schizophrenia
 HEDIS
A/H Cervical Cancer Screening CCS         
 2020-2021
 HEDIS
A/H Childhood Immunization Status 9 CIS   NR     NR 
 2020-2021
 HEDIS
 A Chlamydia Screening in Women 3 CHL         
 2020-2021
 HEDIS
A/H Colorectal Cancer Screening 3,6 COL         
 2020-2021
 HEDIS
A/H Comprehensive Diabetes Care 9 CDC         
 2020-2021
 HEDIS
A/H Controlling High Blood Pressure CBP         
 2020-2021

 10
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Diabetes Monitoring for People With HEDIS
 A SMD NR NR NR NR NR    
 Diabetes and Schizophrenia 2020-2021
 Diabetes Screening for People With
 HEDIS
 A Schizophrenia or Bipolar Disorder Who SSD NR NR NR NR NR    
 2020-2021
 Are Using Antipsychotic Medications
 S Flu Vaccinations for Adults Ages 18 - 64 4 FVA         CAHPS 5.0H
 Follow-Up After High Intensity Care for HEDIS
 A 2 FUI    NR NR    
 Substance Use Disorder 2020-2021
 Follow-Up After Emergency Department HEDIS
 A 2 FUM    NR NR    
 Visit for Mental Illness 2020-2021
 Follow-Up After Emergency Department
 HEDIS
 A Visit for Alcohol and Other Drug Abuse or 2 FUA    NR NR    
 2020-2021
 Dependence
 Follow-Up After Hospitalization for Mental 2, HEDIS
 A FUH         
 Illness 9 2020-2021
 Follow-Up Care for Children Prescribed HEDIS
 A 2 ADD   NR NR NR   NR 
 ADHD Medication 2020-2021
 HEDIS
A/H Immunizations for Adolescents 9 IMA   NR     NR 
 2020-2021

 11
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 International Normalized Ratio Monitoring
 A INR NR NR NR   NR NR NR QRS
 for Individuals on Warfarin
 Kidney Health Evaluation for Patients HEDIS
 A KED    NR NR    
 With Diabetes 2020-2021
 HEDIS
A/H Lead Screening in Children 7 LSC   NR NR NR   NR 
 2020-2021
 Medical Assistance With Smoking and
 S 4 MSC         CAHPS 5.0H
 Tobacco Use Cessation
 Metabolic Monitoring for Children and HEDIS
 A APM   NR NR NR   NR 
 Adolescents on Antipsychotics 2020-2021
 Non-Recommended Cervical Cancer HEDIS
 A NCS   NR NR NR  NR NR 
 Screening in Adolescent Females 2020-2021
 Persistence of Beta-Blocker Treatment HEDIS
 A PBH    NR NR    
 After a Heart Attack 2020-2021
 HEDIS
 A Pharmacotherapy for Opioid Use Disorder POD    NR NR    
 2020-2021
 Pharmacotherapy Management of COPD HEDIS
 A PCE    NR NR    
 Exacerbation 2020-2021
 A Proportion of Days Covered PDC NR NR NR   NR NR NR PQA 

 12
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 HEDIS
 A Risk of Continued Opioid Use COU    NR NR   
 2020-2021
 Statin Therapy for Patients With HEDIS
 A SPC    NR NR    
 Cardiovascular Disease 2020-2021
 HEDIS
 A Statin Therapy for Patients With Diabetes SPD    NR NR    
 2020-2021
 HEDIS
 A Use of Imaging Studies for Low Back Pain LBP         
 2020-2021
 HEDIS
 A Use of Opioids at High Dosage HDO    NR NR    
 2020-2021
 HEDIS
 A Use of Opioids from Multiple Providers UOP    NR NR    
 2020-2021
 Use of Spirometry Testing in the HEDIS
 A SPR    NR NR    
 Assessment and Diagnosis of COPD 2020-2021
 NYS
 A Viral Load Suppression 8 VLS NR NR NR NR NR   
 2020-2021
 
 Weight Assessment and Counseling for
 HEDIS
A/H Nutrition and Physical Activity for WCC   NR     NR
 2020-2021
 Children/Adolescents

 13
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Access / Availability of Care
 Adults’ Access to Preventive/Ambulatory HEDIS
 A AAP    NR NR    
 Health Services 2020-2021
 HEDIS
 A Annual Dental Visit ADV NR NR NR    NR NR 
 2020-2021
 Initiation and Engagement of Alcohol and
 HEDIS
 A Other Drug Abuse or Dependence IET         
 2020-2021
 Treatment
 Initiation of Pharmacotherapy upon New NYS
 A POD-N NR NR NR NR NR    
 Episode of Opioid Dependence 2020-2021
 HEDIS
A/H Prenatal and Postpartum Care PPC         
 2020-2021
 Use of First-Line Psychosocial Care for
 HEDIS
 A Children and Adolescents on APP   NR NR NR   NR 
 2020-2021
 Antipsychotics
 Use of Pharmacotherapy for Alcohol NYS
 A POA NR NR NR NR NR    
 Abuse or Dependence 2020-2021
 Health Plan Descriptive Information
Enrollment by Product Line ENP    NR NR    HEDIS

 14
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 2020-2021
 Use of Services
 HEDIS
 A Acute Hospital Utilization AHU    NR NR NR NR NR
 2020-2021
 HEDIS
 A Ambulatory Care AMB NR NR NR NR NR   
 2020-2021
 HEDIS
 A Antibiotic Utilization ABX    NR NR   
 2020-2021
 HEDIS
 A Child and Adolescent Well-Care Visits 9 WCV   NR     NR 
 2020-2021
 HEDIS
 A Emergency Department Utilization EDU    NR NR NR NR NR
 2020-2021
 HEDIS
 A Frequency of Selected Procedures FSP    NR NR   
 2020-2021
 HEDIS
 A Bariatric Weight Loss Surgery    NR NR   
 2020-2021
 HEDIS
 A Tonsillectomy    NR NR   
 2020-2021
 A Hysterectomy, Vaginal & Abdominal    NR NR    HEDIS

 15
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 2020-2021
 HEDIS
 A Cholecystectomy, Open & Laparoscopic    NR NR   
 2020-2021
 HEDIS
 A Back Surgery    NR NR   
 2020-2021
 Percutaneous Coronary Intervention HEDIS
 A    NR NR NR NR NR
 (PCI) 2020-2021
 NR NR NR HEDIS
 A Cardiac Catheterization    NR NR
 2020-2021
 NR NR NR HEDIS
 A Coronary Artery Bypass Graft (CABG)    NR NR
 2020-2021
 NR NR NR HEDIS
 A Prostatectomy    NR NR
 2020-2021
 HEDIS
 A Mastectomy    NR NR   
 2020-2021
 HEDIS
 A Lumpectomy    NR NR   
 2020-2021
 Identification of Alcohol and Other Drug HEDIS
 A IAD    NR NR   
 Services 2020-2021

 16
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Inpatient Utilization–General HEDIS
 A IPU NR NR NR NR NR   
 Hospital/Acute Care 2020-2021
 HEDIS
 A Mental Health Utilization MPT    NR NR   
 2020-2021
 HEDIS
 A Plan All-Cause Readmission PCR        
 2020-2021
 Well-Child Visits in the First 30 Months of HEDIS
 A 9 W30   NR     NR 
 Life 2020-2021
 Experience of Care
 CAHPS Health Plan Survey 5.0H HEDIS
 S 4 CPA    NR NR 2021 2021 2021
 Adult Version 2020-2021
 CAHPS Health Plan Survey 5.0H HEDIS
 S 4 CPC NR NR NR NR NR 2020 NR NR
 Child Version 2020-2021
 De-identified
 S QHP Enrollee Experience Survey NR NR NR   NR NR NR QRS
 member file
 Measures Collected Using Electronic Clinical Data Systems
 HEDIS
 E Breast Cancer Screening 6 BCS-E    NR NR    
 2020-2021
 HEDIS
 E Colorectal Cancer Screening 6 COL-E    NR NR    
 2020-2021
 17
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Follow-Up Care for Children Prescribed HEDIS
 E ADD-E NR NR NR NR NR NR NR NR 2020-2021
 ADHD Medication
 HEDIS
 E Adult Immunization Status AIS-E    NR NR    2020-2021 
 Depression Remission or Response for HEDIS
 E DRR-E NR NR NR NR NR NR NR NR 2020-2021
 Adolescents and Adults
 Depression Screening and Follow-Up for HEDIS
 E DSF-E    NR NR    2020-2021 
 Adolescents and Adults
 Prenatal Depression Screening and HEDIS
 E PND-E NR NR NR NR NR NR NR NR 2020-2021
 Follow-Up
 Postpartum Depression Screening and HEDIS 
 E PDS-E 2021 2021 2021 NR NR 2021 2021 2021
 2020-2021
 Follow-Up
 HEDIS
 E Prenatal Immunization Status PRS-E    NR NR    2020-2021 

 Unhealthy Alcohol Use Screening and HEDIS
 E ASF-E NR NR NR NR NR NR NR NR 2020-2021
 Follow-Up

 18
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 Patient-Level
 Product Lines
 M Detail
Q e All-
A t Alpha Qualified
 Measure Flag Commercial Medicaid Specs Products
R h Name Health Plans
 required to
R o report
 d PPO/ HMO/ PPO/ HMO/ HMO/ HIV
 EP HARP measure in
 EPO POS EPO POS PHSP SNP
 PLD File
 Utilization of the PHQ-9 to Monitor
 HEDIS
 E Depression Symptoms for Adolescents DMS-E NR NR NR NR NR NR NR NR
 2020-2021
 and Adults
 NYS-Specific Prenatal Care Measures
 These prenatal care measures will be calculated by the Office of
 NYS
 A Risk-Adjusted Low Birth Weight Quality and Patient Safety using the birth data submitted by
 2020-2021
 plans and the Department's Vital Statistics Birth File.
 Commercial EPO/PPO, HMO/POS, Qualified Health Plans NYS
 A Prenatal Care in the First Trimester
 PPO/EPO, HMO/POS, Medicaid HMO/PHSP, Medicaid HIV 2020-2021
 SNP, HARP and EP are required to submit live birth files. NYS
 A Risk-Adjusted Primary C-Section
 2020-2021
 NYS
 A Vaginal Births after C-Section
 2020-2021

 19
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

II. Reporting Requirements

 NYS-Specific Behavioral Health Measures
 Maintaining/Improving Employment or NYS
 A
 Higher Education Status These measures will be calculated and reported by New York 2020-2021
 Maintenance of Stable or Improved State using the NYS Community Mental Health Eligibility NYS
 A
 Housing Status Assessment. HARP members are required to be assessed for 2020-2021
 No or Reduced Criminal Justice Behavioral Health Home and Community Based Services (BH NYS
 A
 Involvement HCBS) eligibility using the NYS Community Mental Health 2020-2021
 Percentage of Members Assessed for Eligibility Assessment at the time of enrollment and at least
 annually thereafter. NYS
 A Home and Community Based Services
 2020-2021
 Eligibility
 Potentially Preventable Mental Health This measure will be calculated by New York State using 3M NYS
 A
 Related Readmission Rate 30 Days Software and health plan submitted encounters. 2020-2021
 Utilization of Recovery-Oriented Services This measure will be calculated and reported by New York NYS
 A 8 URO
 for Mental Health State. No plan reporting is required. 2020-2021

 20
Method Flag
A - admin, H - hybrid, S - survey, E - electronic 1 = Use members in WCC for 12-17 stratum. - Reporting Required MY2020 and MY2021
 2 = Enhanced for Medicaid; separate file required.
Product lines 3 = Enhanced for Medicaid; separate file not required. Purple – Not Required
EPO - Exclusive Provider Organization 4 = DOH conducts Medicaid/HARP/HIVSNP CAHPS.
PPO - Preferred Provider Organization 5 = Administrative method only for QARR. Orange – New Measure
HMO - Health Maintenance Organization 6 = Medicaid follow commercial specifications.
POS - Point of Service 7 = Commercial plans follow Medicaid specifications. Gray- Not required for MY2020 reporting
PHSP - Prepaid Health Services Plan 8 = DOH calculated; no plan reporting required.
HIVSNP - HIV Special Needs Plan 9 = QHP only report numerators required by CMS.
HARP - Health and Recovery Plan
EP - Essential Plan

III. Audit Requirements

III. Audit Requirements
• All organizations must contract with an NCQA-licensed audit organization for an audit of
 their Commercial PPO, Commercial EPO, Commercial HMO, Qualified Health Plan PPO
 Qualified Health Plan EPO, Qualified Health Plan HMO, Qualified Health Plan POS,
 Medicaid, HIVSNP, HARP, and EP QARR data, as applicable.
• All organizations must send a copy of the written agreement with an NCQA-licensed audit
 organization by December 3, 2020. The copy can be sent in PDF format via email to:
 QARR Unit
 Office of Quality and Patient Safety
 Email: nysqarr@health.ny.gov
• Commercial PPO, Commercial EPO, Commercial HMO, and EP health plans must use a
 certified CAHPS vendor for the CAHPS survey and have the sample frame reviewed and
 approved by their auditor.
• Insurers offering a Qualified Health Plan PPO, Qualified Health Plan EPO, Qualified Health
 Plan HMO, and Qualified Health Plan POS must use a certified CAHPS vendor for the
 enrollee survey and have the sample frame reviewed and approved by their auditor.
• It is recommended that health plans provide a draft version of the IDSS to their auditor along
 with the Medicaid enhancement files, Patient-level Detail files, and live birth files prior to the
 June 15 deadline (recommended by June 8, 2021). Auditors should check for accuracy and
 that the specified variables in the PLD files and the IDSS reconcile.
• A copy of the Final Audit Report (FAR), including identified problems, corrective actions, and
 measure-specific results must be submitted to the Office of Quality and Patient Safety upon
 receipt from your auditor (email to nysqarr@health.ny.gov by July 15, 2021). The FAR must
 contain audit validation signatures.
• NYSDOH requires plans to submit data for all measures indicated in the QARR List of
 Required Measures (Table 1). Plans may not designate a measure as ‘NR -- plan chose not
 to report this measure.’
• Plans may designate a measure “UN” (Unaudited) if reporting a measure that is not required
 to be audited. This result applies only to Board Certification measures.

 21

V. NYS-Specific Measures

 IV. Reporting Schedule
 MY 2020 MY2020 MY 2021 MY2021
 Due Date / Products Due Date / Products
 Destination Destination
NCQA Licensed Audit Organization
Copy of written agreement with an December 3, ✓CPPO December 3, ✓CPPO
NCQA licensed organization that 2020 ✓ CEPO 2021 ✓ CEPO
indicates all products included in the ✓ CHMO ✓ CHMO
audit. Email: ✓ EP Email: ✓ EP
 NYSDOH ✓ MA/CHP NYSDOH ✓ MA/CHP
 nysqarr@health. ✓ HIVSNP nysqarr@health. ✓ HIVSNP
 ny.gov ✓ HARP ny.gov ✓ HARP
 ✓ QPPO ✓ QPPO
 ✓ QEPO ✓ QEPO
 ✓ QHMO ✓ QHMO
 ✓ QPOS ✓ QPOS
QARR Submission
Interactive Data Submission System June 15, 2021, ✓CPPO June 15, 2022, ✓CPPO
(IDSS) Submission by 11:59 p.m. ✓ CEPO by 11:59 p.m. ✓ CEPO
 ET ✓ CHMO ET ✓ CHMO
It is encouraged that plans send a ✓ EP ✓ EP
version of the IDSS to their auditor one To: NCQA ✓ MA/CHP To: NCQA ✓ MA/CHP
week prior to the submission deadline. ✓ HIVSNP ✓ HIVSNP
This review may pick up issues that ✓ HARP ✓ HARP
can be corrected prior to submission ✓ QPPO ✓ QPPO
and will help plans make the ✓ QEPO ✓ QEPO
submission deadline. ✓ QHMO ✓ QHMO
 ✓ QPOS ✓ QPOS
Additional File Submission
Patient-Level Detail file (required for June 15, 2021, ✓CPPO June 15, 2022, ✓CPPO
the indicated product lines). by 11:59 p.m. ✓ CEPO by 11:59 p.m. ✓ CEPO
Enhancement files (optional for MA, ET ✓ CHMO ET ✓ CHMO
HIVSNP, and HARP) ✓ EP ✓ EP
Plans are encouraged to send a To: IPRO via ✓ MA/CHP To: IPRO via ✓ MA/CHP
version of the files to their auditor one FTP site ✓ HIVSNP FTP site ✓ HIVSNP
week prior to the submission deadline. ✓ HARP ✓ HARP
This review may pick up issues that ✓ QPPO ✓ QPPO
can be corrected prior to submission ✓ QEPO ✓ QEPO
and will help plans make the ✓ QHMO ✓ QHMO
submission deadline. ✓ QPOS ✓ QPOS
Live Birth File (required for indicated August 1, 2021, ✓CPPO August 1, 2022, ✓CPPO
product lines). by 11:59 p.m. ✓ CEPO by 11:59 p.m. ✓ CEPO
 ET ✓ CHMO ET ✓ CHMO
 ✓ EP ✓ EP
 To: IPRO via ✓ MA/CHP To: IPRO via ✓ MA/CHP
 FTP site ✓ HIVSNP FTP site ✓ HIVSNP
 ✓ HARP ✓ HARP
 ✓ QPPO ✓ QPPO
 ✓ QEPO ✓ QEPO
 ✓ QHMO ✓ QHMO
 ✓ QPOS ✓ QPOS

 22

V. NYS-Specific Measures

 MY 2020 MY2020 MY 2021 MY2021
 Due Date / Products Due Date / Products
 Destination Destination
CAHPS Files
Commercial Survey – de-identified June 15, 2021, ✓CPPO June 15, 2022, ✓CPPO
member-level files of CAHPS by ✓ CEPO by ✓ CEPO
responses are required. Follow NCQA 11:59 p.m. ET ✓ CHMO 11:59 p.m. ET ✓ CHMO
CAHPS file layout for file submission. ✓ EP ✓ EP
CAHPS sample frames must be To: IPRO via ✓ MA/CHP To: IPRO via ✓ MA/CHP
reviewed by auditor prior to CAHPS FTP site ✓ HIVSNP FTP site ✓ HIVSNP
administration. ✓ HARP ✓ HARP
Insurers with Qualified Health Plans - ✓ QPPO ✓ QPPO
de-identified member-level files of ✓ QEPO ✓ QEPO
Enrollee Survey responses are ✓ QHMO ✓ QHMO
required. ✓ QPOS ✓ QPOS

Final Audit Reports
A copy of the Final Audit Report, July 15, 2021 ✓CPPO July 15, 2022 ✓CPPO
including findings, corrective actions, ✓ CEPO ✓ CEPO
and measure-specific results with Email: ✓ CHMO Email: ✓ CHMO
signatures is required. Final Audit NYSDOH ✓ EP NYSDOH ✓ EP
Report submissions are required to nysqarr@health. ✓ MA/CHP nysqarr@health. ✓ MA/CHP
include the specified information for all ny.gov ✓ HIVSNP ny.gov ✓ HIVSNP
supplemental database use. ✓ HARP ✓ HARP
 ✓ QPPO ✓ QPPO
 ✓ QEPO ✓ QEPO
 ✓ QHMO ✓ QHMO
 ✓ QPOS ✓ QPOS

 NYSDOH requires all reporting entities to submit all components per above schedule. Organizations who
 do not submit the IDSS by the submission deadline will be given a Statement of Deficiency (SOD) for
 failure to meet program requirements for performance data reporting. Plans unable to meet the deadline
 submission may request an extension for submission prior to June 15, 2021. Reasons for the extension
 request must be provided with the request, and only those requests that have been approved will be
 acknowledged. Questions/Extension Requests to: NYSDOH QARR Unit: nysqarr@health.ny.gov

 23

V. NYS-Specific Measures

V. NYS-Specific Measures
Adolescent Preventive Care

Measure Changes Summary

 • This measure will not be collected for MY2020. We are working to transition these specifications
 away from the use of HEDIS WCC eligible population to a NYSDOH-defined eligible population.

 24

V. NYS-Specific Measures

 Viral Load Suppression

The Viral Load Suppression measure will be calculated by the AIDS Institute and the Office of Quality and
Patient Safety using the NYSDOH HIV Surveillance System.

Calculation of Measures
Upon close of the measurement year (January 1 through December 31) NYSDOH staff will apply an
algorithm to identify Medicaid members who are potentially HIV-positive using available claims
and encounters. This algorithm captures HIV+ Medicaid recipients based on their HIV-related service
utilization, including outpatient visits, laboratory testing, inpatient stays, filling prescriptions for antiretroviral
medications, and HIV Special Needs Plans enrollment. DOH staff will then employ a multistage matching
algorithm to link information on potentially HIV-positive members to the HIV Surveillance System. Newly
identified members are then added to the existing capture of HIV-positive matched members enrolled in
Medicaid.

The HIV Surveillance System provides information on the Viral load suppression levels for all matched
cases. NYS Public Health law requires electronic reporting to the NYSDOH any laboratory test, tests, or
series of tests approved for the diagnosis or periodic monitoring of HIV infection. This includes reactive
initial HIV immunoassay results, all results (e.g., positive, negative, indeterminate) from supplemental HIV
immunoassays (HIV-1/2 antibody differentiation assay, HIV-1 Western blot, HIV-2 Western blot or HIV-1
Immunofluorescent assay), all HIV nucleic acid (RNA or DNA) detection test results (qualitative and
quantitative; detectable and undetectable), CD4 lymphocyte counts and percentages, positive HIV
detection tests (culture, antigen), and HIV genotypic resistance testing.

Reporting Requirements
There are no reporting requirements for plans for this measure to the Office of Quality and Patient Safety.

Description:
The percentage of Medicaid enrollees confirmed HIV-positive who had a HIV viral load less than 200
copies/mL at last HIV viral load test during the measurement year.

Eligible Population:
 Product Line Medicaid HMO/PHSP, Medicaid HIVSNP, Medicaid HARP

 Ages 2 years of age or older.
 Continuous 12 months’ continuous enrollment for the measurement year.
 Enrollment The allowable gap is no more than one month during the measurement year.
 Anchor Date December 31 of the measurement year.

 HIV confirmation Confirmed HIV positive through a match with the HIV Surveillance System.

 Denominator The eligible population.
 The number of Medicaid enrollees in the denominator with a HIV viral load less than
 Numerator 200 copies/mL for the most recent HIV viral load test during the measurement year.

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